Late Stage PD: clinical problems & management issues Miguel Coelho, MD Neurological Department, Hospital Santa Maria Clinical Pharmacology Unit, IMM, Lisbon Portugal 26 September 2014
Nothing to declare. Financial Disclosure
Outline Progression & Staging of Parkinson s disease (PD). The concept of Late-Stage PD (LS-PD). Clinical problems in LS-PD. Management issues in LS-PD.
Progression & Staging Progression of PD Classically regarded as: Increase in the severity of motor symptomseither levodopa-responsive or levodopa-resistant. The emergence of levodopa-induced motor complications (MC). Non motor symptoms (NMS) not included.
Motor progression is non-linear. Motor decline is faster in earlier stages. Schrag 07
Frequency of levodopa-induced MC varies between studies and population recruited. Levodopa-induced dyskinesia reported in community-based observational studies OBSERVATIONAL STUDIES Community-based Cross-sectional Longitudinal Schrag & Quinn 00 Wickremaratchi 11 Dotchin 11 Evans 11 Ahlskog & Muenter 01 Van Gerpen 06 (retrospective) 19% 23% 25% by 8.5 yrs of LD therapy 35% by 8 yrs of FU 40% by 5 yrs of LD therapy 30% by 5 yrs of LD therapy & 59% by 10 yrs of LD therapy Coelho & Ferreira, in press
Last decade, non-motor symptoms (NMS) as important source of disability: Frequency & severity increase with disease duration. Determine disability in later stages of disease. Dementia, psychosis, falls institutionalization Dementia, psychosis, falls,institutionalization. death Coelho 10 & 14; Chaudhuri 06; Aarsland 99,03,07 Hely 05, 08; Forsaa 10; Buter 08; Papapetropoulos 05; Goetz 93,95
Staging of PD Several attempts to stage disease progression. Pre-levodopa era: Hoehn & Yahr (H&Y) staging system Impairment (objective signs) Disability (functional deficits) Advanced stage according to HY staging: Stages 4 or 5 (loss of physical independence). Hoehn & Yahr 67
Levodopa era: Development of MC were noted. They increase in frequency & severity with disease duration. Impact on disability and QoL. Advanced stage in levodopa era: presence of MC (or disabling MC). Advanced stage Tolosa & Katzenschlager: cardinal symptoms plus disease-related or druginduced motor and non-motor complications. Tolosa & Katzenschlager 07; Hoehn & Yahr 67; Marras 04; Schrag 00; Goetz 04; Obeso 00; Slawek 05
Overall, Advanced stage defined based upon: disease-related motor symptoms (e.g. HY) drug-induced motor symptoms (e.g. MC)
Concept of Late-Stage PD Considerable heterogeneity in advancedstage PD The phenotype of PD patients in many studies of advanced PD do not fulfill the usual definition of advanced-stage. Hely 05, 08; Coelho 10 & 14; Papapetropoulos 05, 07; Martin 73; Kempster 07, 10; Apaydin 02
Heterogeneity in advanced stages of PD More nuanced definitions of the later stages of PD are needed Coelho & Ferreira 12
L-dopa induced-mc & NMS in selected studies Coelho & Ferreira 12
Disability: L-dopa resistant motor symptoms NMS Coelho et al 2010 Hely et al 2008
This progression of disability also applies to DBS patients Castrioto 11 Deuschl 06
Progression of PD in the post-levodopa & DBS era Coelho & Ferreira 12
The concept of late-stage PD (LS-PD) At least a small subset of advanced-stage PD progress to a later, distinct phase of disease. ADVANCED-STAGE PD Without DBS With DBS LATE-STAGE PD
A proposed definition for late-stage PD Patients who progress beyond advanced-stage. Highly dependent on caregivers for ADL. Dependency due to: treatment-resistant motor symptoms. NMS. Operational definition: Schwab & England Scale. Coelho & Ferreira 12
LS-PD < 50% Schwab & England Scale, during on period 50% More dependent. Help with half, slower, etc. Difficulty with everything. 40% Very dependent. Can assist with all chores, but few alone. Coelho & Ferreira 12
Clinical Features of LS-PD N = 50 Coelho 10; Coelho 14, in press
Coelho 10
Handicap Axial + NMS Coelho 10; Coelho 14, in press
Health Care use, Residence & Caregivers Coelho 14, in press
Caregivers Burden Time spent caregiving Variable Mean Standard deviation Median Time spent on informal caregiving (measured as y days x 24 hours/ week) 5 days/week (meaning 5 x 24 hours/week) 2.57 7 days/week (meaning 7 x 24 hours/week) Caregivers burden Mean: 3.5 (SD 0.8) (No impact: 0; major impact: 4) Correlated with patients handicap (r = - 0.5; p< 0.01) Domains: Mobility and Orientation (p< 0.05) Coelho 14, in press
Sydney s cohort Increase from 15 to 20 yrs of PD: Dementia Visual hallucinations Falls Urinary dysfunction Hely et al 05 & 08
Some symptoms cluster before death Kemspter 07 & 10
Disability milestones Coelho & Ferreira 12
Management Issues in LS-PD Patients tend to withdraw from specialized medical care. Patients & caregivers: special needs. Heavy burden for health-care systems and families. Orphan-like disease: patients left out from clinical trials. disability milestones not usual outcomes in RCTs.
Focus on: Unmet needs in LS-PD NMS: dementia, apathy, depression, psychosis, EDS, urinary dysf axial symptoms: dysphagia, dysarthria, falls, fractures, freezing, gait Motor complications: less a priority. Management strategies: simplify; avoid adverse effects. Multidisciplinary team: PT, OT, SP, nurses, social workers, psychiatrists, psychologists, neurologists
Conclusions Prevalence of LS-PD is likely to increase. LS-PD: patients progressing beyond advancedstage. Highly handicapped. Dependent on caregivers. Handicap: predicted by severity of parkinsonism, dementia and neuropsychiatry complaints. Severe impact on caregivers life. Much time allocated to caregiving. Unmet needs and low use of medical resources.